Basic plan (Bronze)

Blue Shield pays, on average, 60% of covered medical expenses

With low monthly rates in exchange for a higher deductible and more out-of-pocket
costs when accessing services, the Basic plan is a good choice if you want to know
you’ve got the coverage you need when you need it most. Most services are subject
to the medical deductible, but you’ll still receive important benefits like preventive
care and three doctor visits for a fixed copayment before meeting the deductible.

This plan is available for purchase directly through Blue Shield or through Covered
California.

Basic plan (Bronze) – Benefit Overview

Benefit

Participating providers1 (PPO and EPO):

Non-participating providers1 (PPO only):

Office visit - primary care doctor

$60 for first 3 visits per calendar year prior to deductible, then $60 after deductible2

50%

Office visit - specialist doctor

$70

50%

Urgent care visit

$120 for first 3 visits per calendar year prior to deductible, then $120 after deductible2

50%

Preventive health benefits

$02

Not covered

Inpatient hospitalization

30%

50%

Outpatient surgery

30%

50%

Lab

30%

50%

X-ray

30%

50%

Emergency room services not resulting in admission

$300

$300

Maternity

30%

50%

Generic drugs

$194

Not covered

Preferred brand drugs

$504

Not covered

Non-preferred brand drugs

$754

Not covered

Chiropractic

Not covered

Not covered

Acupuncture(from a licensed acupuncturist)

$60

$60

Pediatric eye exam

$02

Up to $302

Pediatric eyeglasses

$02

$55 single vision2

Calendar-year medical deductible3

$5,000 per individual / $10,000 per family

$5,000 per individual / $10,000 per family

Calendar-year out-of-pocket maximum(includes deductible)

$6,350 per individual / $12,700 per family

$9,350 per individual / $18,700 per family

Calendar-year brand drug deductible

$04

Not covered

Get complete health plan details

For complete plan details on our
Basic PPO and Basic EPO plans, see the Benefit Summaries and Legal Disclosures below:

We also have Summary of Benefits and Coverage Forms that can help you make a decision
by providing you with an easy to understand overview of what these plans cover.
Visit
blueshieldca.com/sbc to obtain the forms.

Pediatric dental is an essential health benefit for children under age 19, and must
be purchased when applying for a medical plan directly through Blue Shield. We offer
four pediatric dental plans to choose from. Download our pediatric dental plans
flier for more
information.

1 The amounts indicated represent the member’s responsibility, and are a percentage
of the allowable amounts. Participating providers accept Blue Shield's allowable
amounts as payment-in-full for covered services.2 Benefit is available prior to meeting any deductible.3 For family coverage, individuals must satisfy their own individual
deductible, unless a combination of three or more covered family members satisfies
the family deductible. This satisfies the deductible for all covered family members
for the remainder of the year.4 Prescription drugs are subject to the calendar-year medical deductible.

Privacy Information
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We will use the information you provide on this form only to contact you about Blue
Shield health plans. We will not share or sell your information. For more information
about our confidentiality and privacy practices, please send us an email or click here.

Page last updated
02/16/15.

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